HIV treatment needs a shift in thinking - researchers

Experts say more focus on early treatment rather than waiting for CD4 counts will dramatically reduce viral replication and new infections.

Stellenbosch University researchers have called on the scientific and activist communities to “cease debating who is ‘eligible’ or not for HIV treatment” in favour of allowing patients to “make the decision for themselves in consultation with a supportive and well-trained health care worker”.

Currently, doctors in South Africa’s public health system use a CD4 count – a measure of the strength of someone’s immune system – to “measure” whether someone qualifies for treatment.

Last week Health Minister Aaron Motsoaledi announced in his budget vote speech in Parliament that HIV-positive South Africans with a CD4 count of 500 or less, as opposed to the present 350, will be eligible for antiretroviral treatment from January next year.

This brings South Africa in line with World Health Organisation recommendations.

“The eligibility debate is fundamentally ill-advised … and we should rather focus on the challenges around early access to antiretroviral therapy for all,” the authors said in a policy document released last week by the South African Centre for Epidemiological Modelling and Analysis.

Early treatmentThe researchers argue that the reasons for keeping eligibility criteria in place – namely that patients may not adhere to treatment, which could lead to drug resistance or that the over-burdened health system cannot accommodate many more patients – should be “rephrased as practical challenges to be tackled head-on” instead of being used as “reasons for hesitation”.

“When we stop obsessing over the ultimately unanswerable question of when ‘best’ to start treatment, we will have more time, money and energy to deal with the difficulties we will in any case eventually face: of safely maintaining an unprecedented number of patients on long-term medication, and of dealing with the inevitable cost and limitations of such a massive, hopefully sustained, response to a single disease,” lead author Alex Welte said.

The study authors note the major preventative benefits of starting more people on treatment earlier: “Antiretroviral treatment, while not currently able to cure HIV infection, dramatically reduces the rate of viral replication, making it extremely unlikely that a well-treated patient will spread HIV.”

Global targetsThis “shift in thinking”, the authors said, is in line with more ambitious global HIV treatment targets.

The Joint United Nations Programme on HIV and Aids at the 20th International Aids Conference in Melbourne, Australia, last week announced new targets in the global fight against Aids.

These included that 90% of all people living with the virus should be receiving treatment by 2020. Currently, just over 40% of South Africa’s HIV-infected population is receiving treatment, said the researchers.

But Michelle Moorhouse from the Southern African HIV Clinicians Society said ending eligibility criteria is an
“unrealistic” target at present.

“If we suddenly flood the system with millions
of new patients it will be too much strain to handle,” she said.

According to
Moorhouse, drug stock-outs are experienced regularly at many of the country’s
health facilities "which needs to be addressed first – before we plan to expand
the ART programme by so much". She said patients can develop resistance to
their medication if it isn’t taken regularly "and risk transmitting resistant
strains of the virus to other people – compounding the problem".

South Africa has the world’s largest antiretroviral programme with approximately 2.5-million people on treatment, according to health department figures.